Summary Report for FSPSAs Initiated During the Report Period Statewide
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start date of service authorization occurs during the report period). This report does not
represent all FSPSAs that overlap the report period. Note that service authorization periods may
range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs starting between: 10-01-19 and 12-31-19 Date of Report: 02-01-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 14643 FSPSA's found
Services Cpt Code Number of Number of Total Units Total Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Service Coordination, Class # 01
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.800000 $29.6000 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 245 246 411.818765 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 2.285714 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 14 14 373.714287 $13827.4300 $37.0000
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Subtotal (Total Children Is Unduplicated) 260 262 788.618766 $13857.0300 $17.5700
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 82 94 71.671614 $3476.0900 $48.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 251 253 261.857143 $6151.0200 $23.4900
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 2.000000 $76.9400 $38.4700
EVAL -96111 DEVELOPMENTAL EVALUATION 23 30 14.691169 $734.5600 $50.0000
EXIT -EXIT EXIT ASSESSMENT 377 387 613.857992 $30692.8900 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 0.005479 $0.4100 $75.2900
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 0.084932 $6.3700 $74.9700
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 6 6 4.015069 $222.8300 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 18 18 33.005479 $2475.4100 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 9 9 16.005479 $1200.4100 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 5 5 6.008219 $450.6200 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 33 35 59.024657 $3275.8700 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 11 11 19.502740 $1462.7000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 3 4 20.000000 $1000.0000 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 4 4 8.509524 $425.4800 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 0.172222 $8.7900 $51.0400
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 0.294444 $15.0300 $51.0400
OCTH -97167 OT EVAL HIGH COMPLEXITY 20 20 5.562784 $283.9800 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 0.311111 $15.8800 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 7 8 1.605555 $81.9600 $51.0500
SCREEN-T1023 SCREENING 1 1 1.000000 $50.0000 $50.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 29 30 6.488354 $331.2300 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $48.9400 $48.9400
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Subtotal (Total Children Is Unduplicated) 829 928 1152.673966 $52937.4100 $45.9300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 13 15 24.888889 $124444.5000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.944444 $47.2200 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 7 7 6.300000 $315.0000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 1.166667 $83.5500 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 691 800 712.698512 $35635.1000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 34 35 48.285660 $1207.1400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1374 1502 2351.257879 $117562.7900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 208 216 240.911109 $6022.7700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 803 939 1181.768624 $59088.2900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 79 133 142.922235 $3573.0900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 488 536 737.600388 $36879.9800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 26 44 48.311115 $1207.7900 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1402 1452 1615.919841 $80796.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 195 200 209.938892 $5248.4800 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 4.800000 $120.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 212 231 1455.846031 $72792.3200 $50.0000
INTR -T1013 INTERPRETER 187 222 650.937377 $32546.8600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3493 4654 24529.711445 $245297.1100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 23 26 223.325397 $15954.3700 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 8 8 46.142858 $2639.3600 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 38 41 198.271032 $14164.4600 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 9.714286 $555.2700 $57.1600
RSPT -RSPT RESPITE 1 1 1.000000 $0.0000 $0.0000
SENS -V5264 EARMOLD 3 3 3.000000 $54.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 50 54 319.099604 $22796.4600 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 27.142857 $1552.5700 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 9 9 75.066666 $1041.9300 $13.8800
TRAV -TRAVS Travel by mile 1244 2314 129091.261960 $57445.6100 $0.4500
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Subtotal (Total Children Is Unduplicated) 5289 13453 163959.233768 $939302.0100 $5.7300
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Total 14643 165900.526500 $1006096.4500 $6.0600
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Number of Children (Unduplicated) With at Least One Authorization 5865